Sequential histologic evolution of gallbladder inflammation in acute cholecystitis over the first 10 days after onset of symptoms

Background: The timing of cholecystectomy during acute cholecystitis (AC) is controversial, especially whether it is advisable to perform in patients with duration of symptoms between 3 and 10 days. The purpose of this study is to define clearly the sequential evolution of histological changes following symptoms onset to guide recommendations regarding timing of cholecystectomy. Methods: We identified patients with AC (2005–2018) who had cholecystectomy within 10 days of symptom onset of a first attack of AC. Histologic features of gallbladder injury including cellular and exudative inflammatory response to injury were determined on blinded pathologic slides. Results: One hundred and forty-nine patients were divided into three groups; early—who underwent cholecystectomy 1–3 days after symptom-onset, intermediate—4–6 days, and late—7–10 days. Key features of injury were necrosis and hemorrhage. A subgroup of patients in the early phase developed severe necrosis and hemorrhage of an extent associated with difficult cholecystectomy. Large spikes in extent of necrosis and hemorrhage occurred at 7–10 days. Major inflammatory responses to injury were eosinophilic and lymphocytic infiltration and early fibrosis. Conclusions: Severe necrosis may develop rapidly and be present in the early period after symptom onset of AC. Cholecystectomy may be reasonable in some patients but by day 7–10, severe necrosis and hemorrhage may be expected to be present in most patients.